Provider Demographics
NPI:1003391665
Name:MIRISSIS, MARIA JEAN (MASSAGE THERAPIST)
Entity Type:Individual
Prefix:MRS
First Name:MARIA
Middle Name:JEAN
Last Name:MIRISSIS
Suffix:
Gender:F
Credentials:MASSAGE THERAPIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 FORT SALONGA RD STE 2A
Mailing Address - Street 2:
Mailing Address - City:NORTHPORT
Mailing Address - State:NY
Mailing Address - Zip Code:11768-1465
Mailing Address - Country:US
Mailing Address - Phone:631-343-9194
Mailing Address - Fax:
Practice Address - Street 1:10 FORT SALONGA RD STE 2A
Practice Address - Street 2:
Practice Address - City:NORTHPORT
Practice Address - State:NY
Practice Address - Zip Code:11768-1465
Practice Address - Country:US
Practice Address - Phone:631-343-9194
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-30
Last Update Date:2018-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY006241225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist